Health Plans taking in Medicare funds beware.  The  Department of Health & Human Services Office of Inspector General (OIG) is watching.

OIG says its audit of the New York Hotel Trades Council and Hotel Association of New York City, Inc., Health Benefits Fund (the Fund) found that the Fund  improperly reported $237,000 in Medicare Part B costs that were not reasonable and allowable.  According to OIG, the Fund reported that the Fund paid a total of $8.2 million for services provided to 3,180 plan members on its final 2009 cost report.  Of this amount, the Fund included Medicare Part B costs totaling $237,000  Specifically, the OIG says the Fund reported costs for services to plan members that were not Medicare-eligible, costs for services that were billed to both the Fund and Medicare by contracted providers, and costs for services not eligible for Medicare reimbursement.

While the disallowed costs made up a relatively small percentage of the total costs paid by the Fund, the audit report is notable in that it shows the need for health plans to be prepared to defend costs submitted to Medicare against potential challenge by OIG or other federal oversight officials.

In a separate compliance review, OIG also recently reported that Indiana University Health generally complied with Medicare billing requirements for selected inpatient and outpatient claims.  According to OIG, of 198 sampled claims, 35 selected inpatient and outpatient claims had errors, resulting in overpayments totaling $280,000 from October 2008 through September 2010.  See here.

Health plans and their fiduciaries and sponsors need to keep in mind that Federal health care oversight and enforcement is not just about detecting provider misconduct.  Federal officials also are watching the health plans.  While both audits found substantial compliance, the occurrence of the audits itself merits mention.   While OIG and other federal health program fraud and integrity oversight and enforcement activities against health care providers receive widespread attention, the conduct and results of these activities with regard to health plan often goes largely unremarked.  The OIG reports show that federal officials also are scrutinizing health plans to make sure that Medicare, Medicaid or other program funds are not being improperly expended to or accessed by health plans.  Accordingly, health plans receiving early retiree or other program subsidies, participating as Medicare Advantage plans, receiving subsidies or other federal funds, or coordinating benefits with these and other federal programs should prepare for possible federal review and, if applicable enforcement.

For Help or More Information

If you need help preparing to comply with reviewing and updating, administering or defending your group health or other employee benefit, human resources, insurance, health care matters or related documents or practices, please contact the author of this update, Cynthia Marcotte Stamer.

A Fellow in the American College of Employee Benefit Council, immediate past Chair of the American Bar Association (ABA) RPTE Employee Benefits & Other Compensation Group and current Co-Chair of its Welfare Benefit Committee, Vice-Chair of the ABA TIPS Employee Benefits Committee, a council member of the ABA Joint Committee on Employee Benefits, and past Chair of the ABA Health Law Section Managed Care & Insurance Interest Group, Ms. Stamer is recognized, internationally, nationally and locally for her more than 24 years of work, advocacy, education and publications on cutting edge health and managed care, employee benefit, human resources and related workforce, insurance and financial services, and health care matters. 

A board certified labor and employment attorney widely known for her extensive and creative knowledge and experienced with these and other employment, employee benefit and compensation matters, Ms. Stamer continuously advises and assists employers, employee benefit plans, their sponsoring employers, fiduciaries, insurers, administrators, service providers, insurers and others to monitor and respond to evolving legal and operational requirements and to design, administer, document and defend medical and other welfare benefit, qualified and non-qualified deferred compensation and retirement, severance and other employee benefit, compensation, and human resources, management and other programs and practices tailored to the client’s human resources, employee benefits or other management goals.  A primary drafter of the Bolivian Social Security pension privatization law, Ms. Stamer also works extensively with management, service provider and other clients to monitor legislative and regulatory developments and to deal with Congressional and state legislators, regulators, and enforcement officials concerning regulatory, investigatory or enforcement concerns. 

Recognized in Who’s Who In American Professionals and both an American Bar Association (ABA) and a State Bar of Texas Fellow, Ms. Stamer serves on the Editorial Advisory Board of Employee Benefits News, the editor and publisher of Solutions Law Press HR & Benefits Update and other Solutions Law Press Publications, and active in a multitude of other employee benefits, human resources and other professional and civic organizations.   She also is a widely published author and highly regarded speaker on these matters. Her insights on these and other matters appear in the Bureau of National Affairs, Spencer Publications, the Wall Street Journal, the Dallas Business Journal, the Houston Business Journal, Modern Health Care and many other national and local publications.   You can learn more about Ms. Stamer and her experience, review some of her other training, speaking, publications and other resources, and register to receive future updates about developments on these and other concerns from Ms. Stamer here.

Other Resources

If you found this update of interest, you also may be interested in reviewing some of the other updates and publications authored by Ms. Stamer available including:

• Small Employers Should Evaluate Eligibility For Small Business Health Care Tax Credit
• Health Plan BCBST To Pay $1.5 Million In 1st OCR Enforcement Action Prompted By HITECH Breach Report
• March 21 New Deadline To Comment On Proposal To Extend Minimum Wage, Overtime Rules To In Home Care Workers
• NLRB Report Shows Rise In Unfair Labor Practice Complaints & Formal Proceedings
• Sullivan University System to Pay $483,000 in Back Wages Overtime Violations Stemming From Worker Misclassifications
• New DOL Final Rules Tighten Requirements For Employers To Hire Alien Workers Using H-2B Visas
• OSHA $1Million Award Against AirTran Airways Highlights Retaliation Risks
• HHS Chides Trustmark Life Insurance Company For “Excessive” Health Premium Increases After Affordable Care Act Rate Audit
• Labor Department Final Rule Defines Recreation Vehicle For Longshore & Harbor Workers’ Compensation Act
• Portion of Health Care Costs Paid By Government Programs Rose As Employer Provided & Other Private Health Care Coverage Declined In 2010
• Manufacturer’s Excessive I-9 Documentation Triggers Discrimination Liability
• Stamer Dallas Bar Journal Article Cautions Employers Must Take Holistic Approach To Address Worker Misclassification Risks

For important information concerning this communication click here. THE FOLLOWING DISCLAIMER IS INCLUDED TO COMPLY WITH AND IN RESPONSE TOU.S. TREASURY DEPARTMENT CIRCULAR 230 REGULATIONS.  ANY STATEMENTS CONTAINED HEREIN ARE NOT INTENDED OR WRITTEN BY THE WRITER TO BE USED, AND NOTHING CONTAINED HEREIN CAN BE USED BY YOU OR ANY OTHER PERSON, FOR THE PURPOSE OF (1) AVOIDING PENALTIES THAT MAY BE IMPOSED UNDER FEDERAL TAX LAW, OR (2) PROMOTING, MARKETING OR RECOMMENDING TO ANOTHER PARTY ANY TAX-RELATED TRANSACTION OR MATTER ADDRESSED HEREIN.

©2012 Cynthia Marcotte Stamer, P.C.  All rights reserved.

This entry was posted on Friday, May 18th, 2012 at 1:12 PM and is filed under Claims Administration, ERISA, Fiduciary Responsibility, Health Plans, Human Resources, Medicare Part D, Uncategorized. You can follow any responses to this entry through the RSS 2.0 feed. Both comments and pings are currently closed.